1.

Question

Four patients arrive at the emergency room at once while Michael is working as a triage
nurse. Describe the order from first to last in which he will evaluate each of these
clients.

A. An irritable infant with a fever, petechiae, and nuchal rigidity

B. An ambulatory dazed 25-year-old male with a bandaged head wound

C. A 50-year-old female with moderate abdominal pain and occasional vomiting

D. A 35-year-old jogger with a twisted ankle, having a pedal pulse, and no deformity

2. Question

Which of the following is considered one of the primary survey's priority components
when it comes to a trauma patient?

  A. Brief neurologic assessment

  B. Client's allergy history

  C. Initiation of pulse oximetry

  D. Complete set of vital signs

3. Question

Diaphoresis, lightheadedness, and left-sided chest pain were the main complaints of a
65-year-old patient when they arrived at the triage area. Which category should this
patient be given the highest priority in?

  A. Non-urgent

  B. Urgent

  C. Emergent

  D. High urgent

4. Question

In the ED waiting room, there is a call for assistance, and you respond. On the floor,
there is an elderly patient. List the steps you must take in the correct order.

 A. Perform the chin lift or jaw thrust maneuver

 B. Instruct a nursing assistant to get the emergency cart

 C. Initiate cardiopulmonary resuscitation (CPR)

 D. Establish unresponsiveness

 E. Call for help and activate the code team

5. Question

Which task is best suited for an LPN/LVN when providing care for a sexual assault
victim?

  A. Provide emotional support and supportive communication

  B. Assess immediate emotional state and physical injuries

  C. Ensure that the “chain of custody” is maintained

  D. Collect hair samples, saliva swabs, and scrapings beneath fingernails

6. Question

You are helping a patient whose feet have frostbite. Put the ensuing interventions in the
appropriate sequence.

 A. Apply a loose, sterile, bulky dressing

 B. Immerse the feet in warm water 100° F to 105° F (40.6º C to 46.1° C)

 C. Administer pain medication

 D. Remove the victim from the cold environment.

  D. Monitor for signs of compartment syndrome

7. Question

After an urgent endotracheal intubation, nurses need to check the tube's placement and
secure it. What are the steps that must be taken to complete this function, and in what
order?

 A. Auscultate the chest during assisted ventilation

 B. Confirm that the breath sounds are equal and bilateral

 C. Obtain an order for a chest x-ray to document tube placement

 D. Secure the tube in place

8. Question

A male patient, 15, shows up at the emergency room. His shirt and pants are stained
with blood, but he is conscious, coherent, and ambulatory. He is yelling and trying to
explain to his hysterical friends that they were playing around when he got poked in the
abdomen with a stick. Which of the following comments needs to be taken into account
first?

  A. “The stick was really dirty and covered with mud.”

  B. “He pulled the stick out, just now, because it was hurting him.”

  C. “He’s a diabetic, so he needs attention right away.”

  D. “There was a lot of blood and we used three bandages.”

9. Question

A prisoner who has a history of alcoholism has been held by the police for 48 hours. At
first, tremors, sweating, and anxiety were noticed. Now, hypersensitivity, disorientation,
and hallucinations are seen. Dementia tremens is the official medical diagnosis. What
nursing diagnosis should be treated first?
   A. Risk for Injury related to seizures

  B. Risk for Situational Low Self-esteem related to police custody

  C. Risk for Nutritional Deficit related to chronic alcohol abuse

  D. Risk for Other-Directed Violence related to hallucinations

10. Question

Which task should an LPN/LVN be assigned in relation to submersion injuries?

  A. Stabilize the cervical spine for an unconscious drowning victim

  B. Talk to a community group about water safety issues

  C. Monitor an asymptomatic near-drowning victim

  D. Remove wet clothing and cover the victim with a warm blanket

11. Question

You are examining a patient whose left hand has been bitten by a cat. The cat has all
necessary vaccinations. Unknown is when the patient received their most recent
tetanus shot. Which of the following nursing diagnoses should be treated first?

  A. Impaired Skin Integrity related to puncture wounds

  B. Ineffective Health Maintenance related to immunization status

  C. Risk for Infection related to organisms specific to cat bites

  D. Risk for Impaired Mobility related to potential tendon damage

12. Question
A client who was injured multiple times in a one-car rollover shows up. Determine which
interventions for this patient should be started first.

 A. Insert a Foley catheter if not contraindicated

 B. Give supplemental oxygen per mask

 C. Use the chin lift or jaw thrust method to open the airway

 D. Assess for spontaneous respirations

 E. Secure/start two large-bore IVs with normal saline

 F. Obtain a full set of vital signs

 G. Remove the patient’s clothing

13. Question

The MS team transports a 33-year-old patient with a history of seizures and compliance
with phenytoin (Dilantin) and carbamazepine (Tegretol) medication to the ED due to
repetitive seizure activity that began 45 minutes before arrival. Which medication do you
think the doctor will prescribe for status epilepticus?

  A. Phenytoin and Carbamazepine PO

  B. Carbamazepine (Tegretol) IV

  C. Magnesium sulfate IV

  D. Lorazepam (Ativan) IV

14. Question

A patient with multiple physical wounds, including a fractured pelvis from a car accident,
showed up at the emergency room. The client is unresponsive, pale, and diaphoretic
upon assessment. With the following vital signs: 97°F (36.11°C) body temperature,
60/40 mm Hg blood pressure, 143 beats per minute heartbeat, and 30 breaths per
minute respiratory rate. Which of the following shocks is the main cause of the client's
suffering?
   A. Distributive

  B. Hypovolemic

  C. Obstructive

  D. Cardiogenic

15. Question

Cole, an emergency room nurse, came into contact with a patient who may be a carrier
of a biologic agent. Which one of these, if it is discovered in the patient, is not a
Category A biologic agent?

  A. Bacillus anthracis (anthrax)

  B. Francisella tularensis (tularemia)

  C. Clostridium botulinum toxin (botulism)

  D. Burkholderia pseudomallei (Melioidosis)

  E. Yersinia petis (plague)

16. Question

A 15-year-old male client was sent to the emergency unit following a small laceration on
the forehead. The customer claims he is unable to move his legs. After evaluation, the
patient had a capillary refill time of less than 2 seconds and a respiratory rate of 20.
Which triage category would you put this client in?

  A. Red

  B. Black

  C. Yellow

  D. Green
   E. White

17. Question

A 50-year-old woman who occasionally experiences dizziness and heart palpitations is

being cared for by an ER nurse. The diagnosis of paroxysmal supraventricular
tachycardia is confirmed by an ECG. The customer appears concerned about it. Which
of the following is the nurse's proper response?

  A. “You can be discharged now; this is a probable sign of anxiety.”

  B. “The physician will prescribe you blood-thinning medications to lessen the
episodes of palpitations.”

  C. “We’ll need to keep you for further assessment; you may develop blood
clots.”

  D. "You have to stay here for a few hours to undergo blood tests to rule out
myocardial infarction.”

18. Question

Due to abdominal trauma brought on by a motorcycle accident, a patient was brought to

the emergency department. The client complains of back pain and epigastric pain
during the assessment. Which of the following statements about pancreatic injury
diagnosis is accurate?

  A. Redness and bruising may indicate the site of the injury in blunt trauma

  B. The client is symptom-free during the early post-injury period

  C. Signs of peritoneal irritation may indicate pancreatic injury

  D. All of the above

19. Question
A 20-year-old male patient who had been shot in the chest was brought to the
emergency room. Which of the following questions should the nurse ask in order to get
the incident's history in order to identify any potential injuries?

  A. "How long ago did the incident occur?"

  B. "What was the initial first aid done?"

  C. "Where did the incident happen?"

  D. "What direction did the bullet enter into the body?"

20. Question

The nurse's first course of action when treating a client who has suffered head and neck
trauma following a car accident is to?

  A. Provide oxygen therapy

  B. Initiate intravenous access

  C. Immobilize the cervical area

  D. Do oral and nasal suctioning